Transcript Lecture_Spine_Conditions

An orthopaedic overview
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Review of anatomy
Cervical Spine
◦ Review of conditions/ management
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Thoracic spine
◦ Review of condition/ management
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Lumbar Spine
◦ Review of conditions/ management
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Degenerative Disc Disease
Traumatic Conditions
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Nerve root - burners
Whiplash
Muscle strains
Torticollis
Ligament instability/ segmental instability
 Atlanto-axial, other
◦ Neck fractures
 Type 1, 2, 3, hangman
◦ Prolapse of disc
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Degenerative Disc Disease
◦ Gradual onset of wear and tear on disc
from loads
◦ Decreased height of disc due to loss of
water content
◦ Tearing of outer fibrotic layers of disc
(annulus)
◦ Increases likelihood of nucleus tracking
into the outer layers and creating bulges
◦ Symptoms include chronic neck pain,
possible neurological features from nerve
root pressure
◦ Associated osteophyte formation b/w
vertebrae especially at facet joints
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Xray findings- loss of intervertebral spacing,
osteophyte formation b/w vertebrae and at
facet joints
Treatment: symptomatic, short or long-term
analgesia, physiotherapy for ROM,
mobilization, strengthening, avoid
aggravating activities: loading spine etc.
MOI:
 A distraction or stretch injury causing a momentary
stretch injury to the upper cords of the brachial
plexus.
 The extended C-spine is compressed and rotated
toward the painful arm. Injury occurs because the
cervical nerves are tethered by fibrous tissue
between the vertebral arteries and the distal
foramina at each cervical level. These dentate
ligament attachments become taut and stretch the
cervical nerve roots as they leave the spine.
 Arm weakness and burning sensation from 2
minutes to 24 hours
 Self-limiting
 Symptoms reproduced by Spurling test
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Forceful abrupt movement of neck
Hyper-extension, flexion, lateral
Headache, neck pain stiffness, paraesthesia,
radiating pain to shoulders, dizziness
Quebec severity classification of Whiplash
Associated Disorders (WAD)
Assess for C/S fracture, instability (on scene and
imaging) refer to Canadian C-Spine Rules
Rest/ ice, NSAIDs, restricted activity, physiotherapy
to progress and mobilize
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Refers to flexion and rotation of neck due
to muscle contraction: often due to acute
neck injury
Spasmotic Torticollis: refers to chronic
neurological disorder causing involuntary
movements of the neck/head (dystonia)
Predominately idiopathic, some secondary
causes
Onset b/w 30-50 yrs, strong family
history
Evaluation: neurological assessment,
review of meds, ROS,
Referral for specialist assessment and
imaging
Treatment: multi-faceted, targeted at
involved muscles, underlying conditions
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Atlanto-axial (C1/C2) (>3mm spacing)
Traumatic vs. degenerative (RA), congenital
(connective tissue disease)
Instability can cause cord compression
Symptoms: coordination, gait, neck pain, sensory
changes, upper motor neuron sign
Assess symptoms, immobilize and image if acute
onset post trauma. (Canadian C-Spine rules)
Requires emergency and surgical evaluation if
confirmed instability
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Simple wedge fracture
o Fracture of the anterosuperior end plate of the vertebral body
o Associated with posterior ligament disruption, which makes
the injury unstable
o Differs from a burst fracture because no vertical element to
the fracture is present
Anterior teardrop fracture
o Teardrop fracture with an anteroinferior vertebral body
fragment
o Unstable fracture associated with complete disruption of
ligaments
o Associated with anterior cord syndrome
Clay shoveller's fracture
o Avulsion of spinous process of the lower cervical vertebrae,
usually C7
o Stable fracture
Atlantooccipital and atlantoaxial dislocation with fracture
o High instability
o High mortality
Bilateral facet dislocation with fracture
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Anterior arch of the atlas (avulsion fracture) – Unstable fracture
Posterior arch of the atlas fracture
o Compression between the axis and occiput
o High association with other fractures
Hangman's fracture
o C2 pedicles with anterior displacement
o Common in diving accidents
o NOTE: The patient may be without neurologic deficit, but this
is an unstable fracture
Laminar fracture
o Subtle fracture associated with spinous process fractures
o Stable fracture
Extension teardrop fracture
o Anteroinferior vertebral body fracture from an avulsion by the
anterior longitudinal ligament
o Most common at C2
o Unstable fracture
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Pillar fracture
o Vertical or oblique fracture of the articular mass
o Stable fracture
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Pediculolaminar fracture
o Variety of severities
o Associated ligamentous injuries
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Jefferson fracture
o The occipital condyles are driven into C1, forcing the lateral masses apart.
o Often associated with rupture of the transverse ligament
o Unstable fracture
Burst fracture
o Axial lode causes the vertebral body to burst.
o Involves both end plates and may intrude into the spinal canal
o Unstable fracture
Spear tackler's spine
o Associated with use of the head as the initial contact in football
o Over time, athletes develop cervical stenosis, posttraumatic changes, and
loss of cervical lordosis.
o Traumatic axial compression can cause compression of the anterior
column, followed by flexion, resulting in a fracture.
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Type I – At the tip superiorly. The transverse
ligament remains intact, and the fracture is stable.
Type II – At the junction of the odontoid and the
body. This is the most common type of odontoid
fracture.
Type III – Through the superior portion of C2 at the
base of the odontoid
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Approach with suspicion. Consider ABCs from the
beginning.
Obtain the history (i.e. MOI) before the physical
examination or movement of the patient.
Determine location and quality of any pain. Ask if
the pain radiates distally or to the extremities.
Paresthesias or weakness. Other distracting
injuries, HI, or drugs.
Palpate the neck, and specifically feel for midline
bony pain, muscle spasm, step-off, and crepitus.
Determine if extremity sensation is intact. Have
athlete move all extremities without deficits.
Determine if the athlete can perform range of
motion (ROM) in all directions without pain or
symptoms. NOTE: Do not perform passive ROM of
the neck.
Determine if head compression elicits pain or
symptoms.
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Refers to disruption of annulus of intervertebral disc
with extrusion of nucleus pulposus material
Traumatic rupture with forced neck movement
May result in compression of nerve roots
Full C/S and upper extremity exam including
neurological exam: Myotomes, Dermatomes, Reflexes
May immobilize to reduce pain and muscle spasm
Evaluation by physician, surgical team if hard
neurological findings
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Alert (GCS 15) and stable trauma pts
High Risk factor: age>65, numbness in ext,
dangerous mech (fall>3 ft, axial load,
>100km/hr MVC, rollover, ejection
◦ Yes= immobilize and image
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Low Risk factors (allow exam): simple rearend, sitting in ED, Ambulatory, Delayed
onset neck pain, absent midline tenderness
◦ Yes=voluntary ROM to 45 L and R (regardless of
pain)
 Yes/Able= no immobilization, No=immobilize
◦ Not low risk (no ROM exam) = immobilize
*Simple excludes pushed into traffic, hit by
bus/truck/high speed vehicle, or rollover
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Fractures of ribs/ sternum
Fractures of vertebrae
Costochondritis
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Direct trauma, consider force and impact on
underlying lung tissue (contusion/ hemothorax) vs.
pathological fracture
Single vs. multiple ( flail etc)
Assess vitals acutely and in repeated follow up
Clinical exam and Xray for underlying lung injury
Treatment: splinting, analgesia, restrictions
Expect 4-6 wks healing
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Blunt anterior chest trauma
Symptoms: local pain, dyspnea, palpitations
Assess for unstable patients (vitals)
Examine for associated and underlying injury
Treatment: oxygen, IV access, analgesic,
evacuation for additional testing (xray, ecg,
fixation)
Most do not require fixation
4 types
 1. Compression: anterior aspect of body, stable
 2. Burst: whole body +/- unstable
 3. Flexion/distraction: spinous process, pedicle
and vertebral body
 4. Fracture/dislocation: high force in various
directions (flex/ ext, rotation, shear)
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Chest wall pain arising from costochondral joints
Idiopathic abrupt onset , often 2nd or 3rd rib
involved
Ages 20-40
Aggravated by chest wall movement/ respiration
Pain may radiate to shoulders
Exam: swelling of joint with overlying erythema,
painful to palpation
Treat with NSAIDS, ice, rest from activity that
loads/stresses the joint
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Degenerative Disc Disease (DDD)
◦ Loss of vertebral disc height with aging and accelerated by
increased loads
◦ Bulging and tearing of annulus fibrosis
◦ Change in alignment of facet joints
◦ Osteophyte formation
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Clinical: lower back pain, poorly localized, dull to
sharp pain, acute exacerbations of chronic
symptoms with associated with activity
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Exam: decreased AROM, no local tenderness,
+/- muscle spasm
Treatment: conservative, rest, modified
activity, NSAIDS, muscle relaxant prn,
physiotherapy, core strengthening
Rarely surgical decompression +/- fusion
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Acute onset following repeated flexion loading or single
heavy flexion load
Tear in annulus fibrosis allows protrusion of nucleus
pulposus causing disc herniation
Most common levels: L5-S1 >L4-L5 >L3-L4
Lateral herniation produces predominately leg symptoms
(sciatica)
Central herniation produces predominately back pain: large
may produce Cauda Equina syndrome- immediate surgical
evaluation for decompression
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+/- muscle spasm
Neurological testing: decreased power, sensation,
reflex in affected nerve root distribution, Saddle
Symptoms
+ve SLR, femoral nerve stretch
Treatment: Rest, NSAIDS, Physiotherapy,
Consider MRI and surgical consult if “hard”
neurological findings
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Defect in the pars interarticularis of the vertebral
arch
Most occur at L5; may be one or both sides
Often asymptomatic in screening studies
Axial LBP with radiation into legs, sudden or
gradual, worsen with activity
Hyperlordosis and tight hamstrings
One legged hyperextension maneuver is probably
less specific and sensitive than once thought
Dx with X-ray
Conservative, but long, treatment
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Defect in the pars interarticularis of the
vertebral arch on both sides allows body of
vertebra to slip
Grade 1: 1- 25% slippage
Grade 2: 26-50% slippage
Grade 3: 51-75% slippage
Grade 4: 76-100% slippage
Grade 5: Greater than 100% slippage
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Back pain not due to prolapsed disc or other
defined pathology
Aggravated by activity
No neurological findings
Treatment: symptomatic, restricted activities,
physiotherapy
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Causes: mechanical, disc prolapse, traumafracture, exacerbation of chronic condition.
Rule out pathological process: neoplasm,
inflammatory, infectious referred- abdominal
aortic aneurysm
Identify and treat underlying condition
Let’s take a break.